Provider Demographics
NPI:1467887125
Name:BAZEMORE, REGINALD STYLES II
Entity Type:Individual
Prefix:MR
First Name:REGINALD
Middle Name:STYLES
Last Name:BAZEMORE
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 GOVERNORS RD
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:NC
Mailing Address - Zip Code:27983-9763
Mailing Address - Country:US
Mailing Address - Phone:919-805-9379
Mailing Address - Fax:
Practice Address - Street 1:1506 GOVERNORS RD
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:NC
Practice Address - Zip Code:27983-9763
Practice Address - Country:US
Practice Address - Phone:919-805-9379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26933646172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver